nutritional prehabilitation program and cardiac surgery outcome in pediatrics

IOSR Journal of Pharmacy and Biological Sciences (IOSR-JPBS)

e-ISSN: 2278-3008, p-ISSN:2319-7676. Volume 10, Issue 4 Ver. I (Jul - Aug. 2015), PP 46-60 www.iosrjournals.org

DOI: 10.9790/3008-10414660 www.iosrjournals.org 46 | Page

Nutritional Prehabilitation Program and Cardiac Surgery

Outcome in Pediatrics

Mona El-Ganzoury, Rania El-Farrash,GihanFouad, Susan Maher,

Samah Ibrahim 1(Professor of Pediatrics Department, Ain Shams University ,Egypt)

2(Assistant Professor of Pediatrics Department, Ain Shams University ,Egypt) 3(Fellow of Pediatrics ,National Nutrition Institute, Egypt)

4(Head of Pediatric Cardiology Unit ,AtfalMisr hospital ,Egypt) 5(Pediatrician ,ElGalaa Teaching hospital,Egypt)

Abstract:Congenital heart diseases (CHDs) are the most common birth defects with an incidence of approximately 6-8 in 1,000 live births accounting for 6-10% of all infant deaths and 20-40% of all infant deaths

from malformations. Thesedefectsdisruptnormalhemodynamics,causing

pathophysiologyresponsibleforinadequatenutrientintake,insufficientnutrientabsorption,andincreasedmetabolic

demands .The concept of prehabilitation, essentially preparing the patient for the upcoming insult and major metabolic stress, has gained momentum and is of keen interest in many surgical circles.Prehabilitation program

was applied on 40 patients (group A who received nutrition 2 weeks before surgery and group B who received

nutrition 1 week before surgery) inside the postoperative pediatric ICU. Postoperative complications and

mortality were statistically lower in-group A, furthermore, postoperative weight gain, duration of mechanical ventilation, length of hospital stay showed significant difference between both groups.We concluded that the

nutritional and other clinical outcomes as well as fate of the patients were markedly improved after application

of the prehabilitation nutritional program. So we recommend that nutrition delivered to the patients pre and

post operative should be guided by prehabilitation program and with regular assessment of the nutritional

status of the patients clinically and laboratory.

Keywords:Congenital heart diseases,Nutritional status,Prehabilitation nutritional program, Postoperative complications.

I. Introduction Congenital heart diseases (CHDs) are the most common birth defects with an incidence of

approximately 6-8 in 1,000 live births, accounting for 6-10% of all infant deaths and 20-40% of all infant deaths

from malformations [1]. Thesedefectsdisruptnormalhemodynamics,causing

pathophysiologyresponsibleforinadequatenutrientintake,insufficientnutrientabsorption,andincreasedmetabolic

demands [2]. Up to one third of infants born with CHD require surgical intervention early in their lives[3].

Postoperative poor outcomes include not only increase overall mortality but also morbidity, such as increased

hospital stay, increased intensive care unit (ICU) admissions, delayed wound healing, central line-associated

bloodstream infections, surgical site infections, and other infectious complications [4].Nutrition is fundamental

for ensuring adequate energy essential for basal metabolism, growth and physical activity. Infants and children

possess high metabolic rates and limited reserves for endogenous substrates at baseline, so infants and children

are at risk for developing inadequate energy production during episodes of acute or chronic illness [5].There is a

general agreement that enteral nutrition is better than Parenteral nutrition. It is no longer controversialthat early postoperative enteral feeding is beneficial, Early enteralnutrition delivery can decrease infectious complications,

maintainthe integrity of the gut mucosal border, attenuate the metabolic responseto surgical stress, and decrease

mortality [6].The concept of prehabilitation, essentially preparing the patient for the upcoming insult and major metabolic stress, has gained momentum and is of keen interest in many surgical circles [7]. As part of this

prehabilitation concept, the operative team would metabolically assess the patient in some predetermined preoperative

setting and offer guidance for optimal glycemic control and begin an individually tailored exercise program to

enhance lean body tissue and endurance [8].

II. Aim Of The Work This study was done to compare the outcome of malnourished congenital heart surgery patients who

received nutritional pehabilitation program 2 weeks pre-operatively with those who received nutritional

pehabilitationprogram only for 1 week pre-operatively.

Nutritional Prehabilitation Program and Cardiac Surgery Outcome in Pediatrics


III. Patients And Methods 3.1 Patients

This is a prospective study that was carried out on 40 infants underwent open or closed heart surgery for

palliative or corrective repairs for congenital heart disease in Pediatric cardiac surgery ofAtfalMasr Hospital.

3.1.1. Inclusion Criteria:

Infants with congenital heart disease, admitted to cardiothoracic unit for either palliative or corrective surgery,

suffering from nutritional deficiencies with body weights less than 2 SD.

3.1.2.Exclusion Criteria:

1. Congenital or acquired anomaly of gastrointestinal tract . 2. Metabolic or endocrine disease or any systemic illness. 3. Fever or infection within 5 days before the study entry.

3.1.3.Group Classification:The Avaliable patients will be assigned into one of 2 groups:

Group A: included 20 patients who were scheduled for elective surgery called 2 weeks prior to surgery and

received nutritional prehabilitation programs according to the updated guidelines [9].

Group B: included 20 patients who were scheduled for elective surgery called 1 week prior to surgery and

received nutritional prehabilitation programs according to the updated guidelines [9].

3.2.Methods

3.2.1.comprehensive history taking:

Antenatal history:Maternal age, chronic diseases, TORCH infection and medications during this pregnancy .

Natal history: Gestational age according to the guidelines of the American Academy of Pediatrics [10], neonatal sex and mode of delivery.

Postnatal history:Respiratory distress and cyanosis.

Family history: Consanguinity, congenital anomalies, previous abortion, sibling death, and still birth .

3.2.2. Clinical examination:

General assessment including:

1. Type of surgery (open or closed). 2. Original diagnosis. 3. Preoperative investigations, intervention or previous surgery.

Specific nutritional assessment:

Anthropometrical assessment was performed using standardized equipments, and following the recommendations of the International Biological Program [11].

1- Preoperative, early and final postoperative weight (measured on growth curves)

2- Preoperative and postoperative height (measured on growth curves)

3- Body mass index (weight/height)

4- Weight-for-age z score, Height-for-age z score [12].

3.2.3.Laboratory Investigations:

Complete blood picture using Coulter Counter GEN-S (Coulter Corporation, USA) [13].

C-reactive protein was estimated by latex agglutination assay using the AVITEX CRP commercial kit [14].

Coagulation profile.

Blood sugar.

Kidney, serum potassium and serum calcium.

Liver function tests (serum albumin, alanine transaminase and aspartate transaminase). Function tests and electrolytes (blood urea nitrogen, serum creatinin, serum sodium).

Chest x ray and Echocardiography.

3.2.4.Type of Study:

Prospective study was applied with no blinding. In our study, the parents of the studied infants, data collectors, study nurses, laboratory personnel, the supervisors and attending investigator were aware of the nature of the

intervention.



3.2.5 .NutritionalPrehabilitation Program

Pre-operative period: Calculating caloric intake using the recommended dietary allowance (RDA) then increased energy intakes by 30% above RDA with the total caloric intake in the range of 150 to 180 kcal/kg per day [15]. Provide adequate nutrition preferably via enteral feeding (EN) to meet the patients needs until surgery. Our goal was weight gain of 50 to 60 g per day in order to maintain good nutritional health[16]

Post-operative period:Initiate nutrition support as soon as possible to prevent malnutrition and to support functioning of vital organs. Avoid re-feeding syndrome in the infant with significant malnutrition.Avoid

overfeeding, which can cause difficulty in weaning from the ventilator.Reduce unnecessary cessation of EN

[17].

3.3The following outcomes was recorded: 3.3.1. Primary outcomes

The day of successful start of enteral treatment.

Recording enteral feeding pre and postoperative (volume of increment, frequency, type and method of administration) daily.

Recording daily intravenous fluids pre and postoperative (type, concentration, volume).

Recording the total calories taken by the patient daily pre and postoperative.

Weight gain expressed as g/kg/day. Growth expressed as weight, height and Weight for age z score[18]. All the previous parameters will be recorded at admission and at discharge.

Feeding complications (overfeeding, underfeeding ability to feed and feeding tolerance (whether good i.e. no distension, no vomiting or diarrhea, no or minimal residual, fair i.e. mild abdominal distension, mild

vomiting or colic, small residual volume, bad i.e. marked abdominal distension, hematemesis, marked

residual volume more than 60% of the meal)).

3.3.2. Secondary outcomes

Postoperative complications, wound healing and infective complications

Length of ICU stay.

Mortality if present (secondary outcomes).

Respiratory complications e.g. aspiration, pneumonia, respiratory distress, pneumothorax, atelectasis .

Mechanical ventilation (duration, extubated, reventilated or not extubated).

Hemodynamic stability (within the normal average heart rate and blood pressure according to age) and bleeding.

Neurological complications (convulsions, disturbed conscious level or others).

3.4.Ethical Considerations:Collected data have been used for study purpose only. The mothers of the infants

under study were informed about the purpose of the study and of the name of the research institute before

agreeing to participate. They provided informed consent before the testing began.

IV. Statistical Analysis Data were collected, revised, coded and entered to the Statistical Package for Social Science (IBM

SPSS) version 20 .Qualitative data were presented as number and percentages while quantitative data were

presented as mean, standard deviations and ranges. The comparison between two groups with qualitative data

were done by using Chi-square test and/or Fisher exact test was used instead of Chi-square test when the

expected count in any cell was found less than 5.The comparison between two independent groups with

parametric data were done by using Independent sample t-test while the non parametric data were compared by

using Mann-Whitney test. Spearman correlation coefficients were used to assess the relation between two quantitative parameters in the same group.

V. Result This study was carried out on 40 infants with congenital heart disease admitted to Pediatric cardiac

surgery intensive care unit at Ain-Shams University and AtfalMasr Hospital. All of them were fulfilling the

selection criteria of the study.The results of the present study are shown in FollowingTables and Figures.

Table (1): Demographic Characteristics Of The 2 Studied Groups

GroupA

(n=20)

GroupB

(n=20) Test p-value

Malesex,n(%) 13(65.0) 10(50.0) 0.921 0.337

Age(years)

Range 0.6-7.6 0.5-4.2

1.831 0.067 Median 1.25(0.93.34) 0.8(0.551.25)



Table 1 shows no statistically significant difference as regards sex, age between the 2 studied groups (p>0.05).

Table (2):Pre-Nutrition, Pre-Operative Anthropometric Parameters Of The 2 Studied Groups

GroupA

(n=20)

GroupB

(n=20) Test p-value

Weight(kg) MeanSD 9.724.43 6.552.74 2.719 0.010*

Weight-for-agezscore Median(IQR) -2(-3-2) -3(-3-2) -1.392 0.164

Height(cm) MeanSD 86.9026.06 71.2014.17 1.915 0.063

Height-for-agezscore Median(IQR) 0(-12) -1(-21) -1.379 0.168

BMI(kg/m) MeanSD 12.322.41 12.592.55 -0.346 0.731

BMI: Body mass index; *, p



Figure (2):comparison between the 2 studied groups as regards post-nutrition, pre-operative weight.

Figure (3):comparison between the 2 studied groups as regards post-nutrition, pre-operative height

Figure (4):comparison between the 2 studied groups as regards post-nutrition, pre-operative BMI

65

70

75

80

85

90

Group A Group B

Heig

ht

(cm

)

p-value



Figure (5): Comparison between the 2 studied groups as regards post-nutrition, pre-operative

weight-for-age (z score).

Table 3 and fig 2,3,4,5 show post-nutrition, pre-operative anthropometric parameters in the 2 studied groups. A significant increasing weight, weight for age-z score, height and BMI was observed among

group A who received nutritional prehabilitation for 2 weeks before surgical interference when compared to

group B who received nutritional prehabilitation for 1 week before surgical interference.

Table (4):Post-Operative Nutritional Prehabilitation Of The 2 Studied Groups

Group A

(n=20)

Group B

(n=20) Test p-value

n (%) n (%)

Timing of start of post-operative

enteral feeding (days)

1st 16(80.0) 12(60.0)

2.390 0.303 2nd

4(20.0) 7(35.0)

No 0(0.0) 1(5.0)

Method of administration

of enteral feeding

No enteral feeding 0(0.0) 1(5.0)

3.462 0.177 Nasogastric 3(15.0) 7(35.0)

Oral 17(85.0) 12(60.0)

Feeding frequency (every hrs) 2 19(95.0) 16(84.2)

1.232 0.267 3 1(5.0) 3(15.8)

Volume of post-operative feeding (mL/fed) meanSD 37.0010.31 29.4710.79 2.228 0.032*

Figure (6): Volume of post-operative feeding in the 2 studied groups

Table 4 and fig 6 show no statistically significant difference as regards timing of start of post-operative enteral feeding, method of administration of enteral feeding and feeding frequency while there was

statistically significant increase in volume of post-operative feeding in group A who received nutritional prehabilitation 2 weeks before surgical interference compared to group B who received nutritional

prehabilitation 1weeks before surgical interference.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Group A Group B

Vo

lum

e o

f p

osto

pera

tive f

eed

ing

(

mL/fed

)

p-value



Figure (7):feeding intolerance manifestations in the 2 studied groups

fig7show lower incidence of abdominal distention, gastric residual >25%, vomiting, diarrhea and hematemesis among group A patients when compared to group B though not reaching a statistically significant

level.

Figure (8):pre-operative and post-operative anthropometric parameters in group a.

Fig 8show statistically significant increase in post-operative weight and BMI, weight- fore- age z score and height- for-age z score while there wasno statistically significant difference as regards height in group A.

Table (5)Post-operative anthropometric parameters among the 2 studied groups at discharge

Group A

(n=20)

Group B

(n=20) Test p-value

Weight (kg) MeanSD 13.472.84 7.122.82 2.636 0.012*

Weight- for- age z score Median (IQR) 3 (23) 1 (1--2) -3.729 0.000*

Height (cm) MeanSD 87.8518.81 72.1013.46 3.045 0.004*

Height- for- age z score Median (IQR) 0 (02) -1 (-11) -1.006 0.314

BMI (kg/m) MeanSD 17.453.44 13.423.11 2.161 0.047*

Weight gain (Post-operative-pre-operative

weight) (gm) MeanSD 448.57148.16 297.7892.44 2.719 0.013*

Table5show post-operative anthropometric parameters in the 2 studied groups. A significant increase in weight, weight-for-age z score, height, BMI and weight gain was observed among group a patients who received

nutritional prehabilitation for 2 weeks before surgical interference when compared to group b who received nutritional

prehabilitation for 1 week before surgical interference.

0

5

10

15

20

25

30

35

Abdominal distentionGastric residual Vomiting Diarrhea hematemesis

Group A Group B

0

20

40

60

80

100

Weight (kg) Height (cm) BMI (kg/m)

Preoperative Postoperative



Table (6);Pre-operative and post-operative biochemical profile in group B

Pre-operative Post-operative

Test p-value MeanSD MeanSD

Na(mEq/L) 139.256.59 139.486.92 -0.103 0.919

K(mEq/L) 4.330.68 4.650.80 -1.776 0.092

Ca(mg/dL) 9.770.74 9.970.66 -0.792 0.438

Urea(mg/dL) 32.1015.95 39.1417.36 -1.475 0.157

Creatinine(mg/dL) 0.760.31 0.770.42 -0.205 0.840

RBS(mg/dL) 104.9015.13 115.9521.78 -1.863 0.070

CRP 3.081.62 8.356.5 3.518 0.001*

Ca:Calcium;Na:Sodium;K:Potassium,RBS:Randombloodsugar.

DatawereexpressedasmeanSDwhereStudent-ttestwasappliedforcomparisons

Figure (9): Pre-operative and post-operative CRP in group B.

Table 6 and figure 9 show no statistically significant difference as regards post-operative laboratory characteristics, except significant post-operative CRP rise showed between the 2 studied groups.

Table (7): Primary outcomes of the 2 studied groups

Group A

(n=20)

Group B

(n=20) Test p-value

n (%) n (%)

Length of ICU stay (hrs) Median (IQR) 24 (24 48) 60 (38 108) 3.184 0.001*

Duration of post-operative

mechanical ventilation (hrs) Median (IQR) 8 (6 18) 18 (13 47) 2.914 0.003*

Extubation

Early 18(90.0) 15(75.0)

2.273 0.518 late 1(5.0) 3(15.0)

notextubated 0(0.0) 1(5.0)

re-intubated 1(5.0) 1(5.0)

Wean of ventilator No 0(0.0) 1(5.0)

1.026 0.311 yes 20(100.0) 19(95.0)

Inotropes withdrawal No 0(0.0) 1(5.0)

1.026 0.311 yes 20(100.0) 19(95.0)

Clinical evidence of

respiratory

or other infections

No 20(100.0) 18(90.0)

2.105 0.147

Yes 0(0.0) 2(10.0)

Bleeding No 20(100.0) 20(100.0) NA NA

Neurological complications No 20(100.0) 20(100.0) NA NA

02468

10

preoperative postoperative

CRP(m

g/dl)



Figure (10): Duration of post-operative mechanical ventilation in the 2 studied groups.

Figure (11): Post-operative ICU stay in the 2 studied groups.

Table 7 and fig 11-12 show no statistically significant difference as regards clinical evidence of respiratory or other infections, post-operative bleeding, neurological complications, cause of death, successful

Weaning of ventilator, extubation, inotropes withdrawal, but there was statistically significant decrease in

duration of post-operative mechanical ventilation and length of CICU stay was observed among group A who received nutritional prehabilitation for 2 weeks before surgical interference when compared to group B who

received nutritional prehabilitation for 1 week before surgical interference.

Figure (12):Positive correlation between total caloric intake and post-operative weight in group A.



Figure (13):Positive correlation between total caloric intake and post-operative height in group A.

Figure (14):Positive correlation between total caloric intake and post-operative weight-for-age z score in

groupA.

Figure (15):Negative correlation between post-operative BMI and duration of mechanical ventilation in group

A.

(Kca

l/k

g)

(Kca

l/k

g)



Figure (16):Negative correlation between post-operative BMI and length of ICU stay in group A.

Figure (17):Negative correlation between post-operative weight and length of ICU stay in group A.

Figure (18):Negative correlation between post-operative weight-for-age z score and length

of ICU stay in group A.



Figure (19):Positive correlation between duration of post-operative mechanical ventilation and length of ICU stay in

group A.

fig12-18 Show a significant positive correlation between total caloric intake and each of weight, height and weight-for-age z score (p



Malnutrition in the pediatric intensive care unit (ICU) population is a widely acknowledged problem

that may intensify underlying illnesses, increase the risk of complications and affect growth and development.

Nutritional assessment upon admission to the ICU is necessary to identify children at risk and to guide nutritional support during ICU stay [21].

The repertoire of routine laboratory parameters includes several markers (e.g., albumin, urea,

electrolytes) that can provide useful and easily obtainable information regarding nutritional status and

requirements. Abnormalities in these parameters reflect derangements in several metabolic pathways and may

represent the severity of depletions occurring during critical illness[22].

In the current analysis, both groups were comparable as regard baseline demographic, clinical and

laboratory characteristics measured before implementation of any nutritional prehabilitation or surgical

interference. In an earlier study, Hansen and Dorup [23]recorded that caloric intake in patients with CHD was

76% that of normal age-matched controls. Fatigue upon feeding may represent a possible cause to explain the

decreasedintake and chronic hypoxia leads to both dyspnea and tachypnea during feeding, causing the child to

tire easily and thus reduce the quantity of food consumed. Moreover, we found a negative correlation between the baseline pre-operative pre-nutritional

anthropometric measurements including weight and height of all the studied patients with CHD and duration of

hospitalization and mechanical ventilation. Similarly, Bozzetti [24] reported that in pre-operative patients with

protein energy malnutrition, the incidence of post-operative adverse events is reported to be higher than in

patients with normal nutrition status. Moreover, Tokel et al [25]stated that pre-operative severity of malnutrition

is indeed related to the pre-operative and post-operative events.

In the view of the effect of pre-operative nutritional prehabilitation on the anthropometric features of

the 2 studied groups, we observed a highly significant increase in weight, height, BMI and weight-for-age z

score in group A who received nutritional prehabilitation for 2 weeks pre-operatively compared to group B who

received nutritional prehabilitation for only 1 week pre-operatively.

In an earlier study, Potter et al [26] reported that most trials included in his review concluded that nutritional

supplementation improves body weight and anthropometry. Furthermore, aretrospective study conducted by Schuurmans et al [27]observed low pre-operative mean weight-for-age and height-for-age z-scores in 18 Dutch

children with Tetralogy of Fallot, which improved after the introduction of adequate nutritional rehabilitation therapy.

As regard height-for-age Z score, the current study showed no significant change in height post-

nutritional prehabilitation. This could be explained by the fact that changes in height known to be secondary to

chronic changes that take longer time to show the difference than acute change of weight [25].This was further

supported by the positive change in weight-for-age z score and height-for-age z score post-operatively in both

groups.Our nutritional prehabilitation protocol includes not only pre-operative nutritional support, but also post-

operative increased enteral feeding goal rates, in order to allow our patients to receive their goal nutrition

requirements in a 24-hour period post-operatively.

As regards post-operative nutritional outcomes, no significant difference was found between both

groups as regard type of enteral feeding, timing of start, method of enteral feeding and frequency of feeding. However, group A showed significant high volume per fed post-operatively compared to group B. Furthermore,

this nutritional prehabilitation protocol was easily tolerated by patients of both groups with lower manifestations

of feeding intolerance among group A though not reaching statistically significant level.

These results agree with the results recorded by Binnekade[28] who studied the tolerance to enteral

feeding after application of post-operative nutritional protocol in pediatric CICU and concluded that tolerance

was significantly improved after application of such protocol.

Upon comparing pre-operative and post-operative anthropometric features, highly significant increase

in post-operative weight-for-age z score and height-for-age z score in both groups. Furthermore, group A

showed a highly significant increase in post-operative weight and BMI. Moreover, length of ICU stay was

negatively correlated with post-operative anthropometric parameters including weight, weight-for-age z score

and BMI, however didnt reach significant levels in group B. In an additional assessment of the effect of nutritional prehabilitation program, a highly significant

increase in weight, height, BMI, weight-for-age z score and weight gain in group A compared to group B, post-

operatively with a significant positive correlations between post-operative anthropometry and total caloric

intake.The previous findings support those of Beattie et al[29]who studied the application of dietary supplementation

in patients following surgery where weight was slow to recover in the control group compared with the group

receiving post-operative nutritional supplementation. However, we found it unethical to use a control group that has

no pre-operative nutritional support, instead we randomly assigned patients into one of 2 groups receiving pre-

operative nutritional prehabilitation for either one or 2 weeks pre-operatively and continued post-operatively till

discharge.

In agreement with our findings, Anderson et al [30] who examined infants with single ventricle at

Cincinnati Children's Hospital Medical Center reported that optimal nutritional practices after the Norwood



operation led to improve in weight gain. Moreover, Sables-Baus et al [31]carried out retrospective review of

infants admitted with congenital cardiac disease over a period of 1 year and concluded that enteral feeding was

associated with greater weight gain. Upon comparing post-operative hemodynamic data between both groups, we found no significant

difference as regard heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, body

temperature, central venous pressure, urinary output and oxygen saturation.

Upon comparing pre-operative and post-operative hematological and biochemical features of both

groups we found no significant difference except for CRP which showed significant post-operative rise in group

B. However, comparing pre-operative and post-operative hematological and biochemical features between both

groups, we found no significant difference except for post-operative CRP which significantly lower in group A

compared with group B.

This is in concordance with Nakamura et al [32]who studied influence of pre-operative nutritional state

on inflammatory response after surgery and reported that among patient receiving nutritional intervention, the

malnourished group having higher CRP levels than those who were not malnourished . Upon studying the effect of longer pre-operative enteral nutritional intervention on the primary

outcome measures, a significant decrease of the duration of mechanical ventilation and duration of

hospitalization in group A compared with group B was found. Furthermore, we observed that post-operative

weight, BMI, weight-for-age z score were negatively correlated with the length of the intensive care stay, and

that post-operative BMI was negatively correlated with the duration of mechanical ventilation in group A, while

group B showed no significant correlations with the measured outcomes.

In agreement with our results Corkins[33], Yiet al [34], White et al [35] demonstrated that early pre-

operative enteral nutrition decreases infection rates, length of stay and duration of mechanical ventilation.

Moreover, Dong et al [36]reported that duration of mechanical ventilation and length of ICU stay were

significantly reduced in the nutritional rehabilitation group compared with the control group. In this regard,

McClave et al [36]reported improved patient outcomes when a protocol to deliver the caloric and protein goal is

implemented. Furthermore, Deitch et al [38]stated that proper adequate nutritional support may help in achievement of the balance between the calories, proteins and electrolytes delivered to the patients and the

nutritional requirements needed for proper functions of the liver, kidney, brain and heart, improved resistance to

infections, shortened length of hospital and ICU stay, good function of the lungs and early weaning from the

ventilator. Additionally, Somanchi et al [39] observed in their analysis on malnourished hospitalized patients at

the Johns Hopkins Hospital that nutrition screening involving a team approach to address malnutrition and

earlier intervention reduced the length of hospital stay by an average of 3.2 days in severely malnourished

patients.As regards secondary outcomes, all of the included patients were discharged and none of our patients

died during the study.

The limitation of our study includes examining a heterogeneous group of patients of different ages with diseases of

different complexity scores and different types of surgery.

VII. Conclusions and recommendations Early enteral nutrition and adequate preoperative energy intake is correlated with the length of the intensive

care therapy, duration of mechanical ventilation and number of postoperative complications and infections.

Pre-operative nutritional support improves post-operative anthropometric measurements and clinical outcomes in the undernourished CHD patient.

The nutritional and other clinical outcomes as well as fate of the patients were markedly improved after application of the prehabilitation nutritional program.

We recommend that nutrition delivered to the patients in the ICU should be guided by prehabilitation program and that the regular assessment of the nutritional status of the patients clinically and laboratory in

pre- operative and post operative period.

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